Problems in improving cot death investigations 

28 January 2005

New research exposes problems in improving investigations of cot deaths

A study published today , funded by the Foundation for the Study of Infant Deaths (FSID), has identified problems that are preventing paediatricians, pathologists, police and other professionals from working together to conduct improved investigations when a baby dies suddenly and unexpectedly.

Joint working is essential to understand the causes of these tragedies and avoid unnecessary court cases. A working group chaired by Baroness Helena Kennedy published a report last September recommending a standard multi-agency protocol to investigate sudden infant death. FSID has been campaigning for five years for local professionals to adopt such a protocol and many have done so – or at least they have agreed a protocol on paper but FSID has long had concerns that the transition to practice was not actually taking place.

Dr Anne Livesey, a paediatrician, was commissioned by FSID to conduct the first-ever audit of a protocol. Published today, it reveals serious failures:
• no-one is being appointed to take responsibility to ensure implementation. Currently this responsibility falls between Chief Executives of several agencies
• professionals’ interpretation of the protocol varied
• some professionals in the area are not even informed that a protocol has been adopted
• there is inadequate training or no training at all in new working practices
• some diagnoses in babies who have died unexpectedly are being made without consistent and thorough investigation.

Dr Richard Wilson, paediatrician and FSID trustee, said:

“Failure by health professionals, the police and social services to work together in investigating infant deaths increases the risk that cases of child abuse will go unidentified or that innocent parents will suffer miscarriages of justice. In FSID’s experience, Dr Livesey’s findings are typical. Efforts to encourage agencies to voluntarily introduce change are not working. Although there are some areas which are making exceptional efforts it is time for improved investigation of cot deaths to be made mandatory. FSID calls on the government to make the recommendations in the Kennedy report mandatory with out further delay”.

Notes to editors:

1. The Foundation for the Study of Infant Deaths is the UK’s leading baby charity working to prevent deaths and promote health. FSID funds research into the causes and prevention of sudden infant deaths, supports bereaved families and promotes safe baby care advice to parents and professionals.

2. FSID’s campaign for a standard protocol to improve professional responses
to all sudden infant deaths has three key recommendations:

• A paediatrician, working in conjunction with the police, should visit each family within 24 hours of the death to take a complete medical history and offer initial support to the family
• All post mortem examinations should be carried out by a paediatric pathologist, a specialist in babies’ disorders
• A case discussion should be held with all the professionals who were involved with the family or the baby to review all available information, learn as much as possible about why that baby died, and plan future support for the family

3. Editors are encouraged to include FSID’s Helpline number (0870 787 0554)
with any reporting.

4. Interviews with Dr Anne Livesey, FSID representatives and cot death parents should be possible.

Media enquiries:

Sarah Kenyon
Communications manager 0870 787 0726 / 07981 899 827

 

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